Why the location, intensity, and number of sessions can be the difference between remission and no response
| IN SHORT TMS is not a single, standardized treatment. Where the coil is aimed, how strong the pulses are, and how many sessions a person receives all shape the outcome. Two clinics can both offer TMS and get very different results. That is why experience across multiple TMS technologies and protocols matters, and why TMS Life built a treatment resistant pathway that adjusts based on how each person actually responds. |
If you have looked into TMS, or transcranial magnetic stimulation, for depression or another mental health condition, you have probably heard that it works. And it does, for a lot of people. But there is a detail that often gets left out of the conversation: TMS is not one single, uniform treatment. It is a family of techniques, and the way it is delivered can be the difference between a person going into remission and a person walking away feeling like nothing changed.
At TMS Life, we see this firsthand every week. Someone comes to us after a course of TMS elsewhere that did not work, and once we adjust the target, the strength of the pulses, or the pacing of sessions, we see real movement. This article walks through why those details matter so much, and what we do differently.
What TMS Actually Is
TMS uses a magnetic coil placed against the scalp to generate a brief magnetic field. That field passes painlessly through the skull and creates a small electrical current in the brain tissue underneath, which activates nearby neurons. Done repeatedly over a course of treatment, this can help retrain brain circuits that are involved in depression, anxiety, PTSD, and other conditions. It is non-invasive, does not require anesthesia, and patients can drive themselves home afterward.
That basic description covers almost every form of TMS on the market. But underneath that umbrella sit a lot of choices, and those choices are where outcomes are decided.
Location: Where the Coil Is Aimed Changes Everything
The brain is not a single button you press. Depression and related conditions involve specific networks, and the most studied target is a region called the dorsolateral prefrontal cortex, or DLPFC. But everyone’s brain is shaped a little differently, and a target that works well on average across a group of patients is not necessarily the right spot for the person in the chair.
Research bears this out. Studies comparing different coil designs have found remission rates ranging from about 10 percent with one coil type up to 60 percent with another, depending on how the field reaches the target tissue. Newer work using brain imaging to personalize the exact stimulation site, rather than relying on scalp measurements or population averages, has reported response rates as high as 85 to 90 percent in early studies, compared with the 40 to 58 percent response rates typically seen with standard, non-personalized targeting.
In plain terms, missing the mark by even a small margin, or using a generic target instead of one suited to that person’s anatomy, can be the reason TMS falls flat.
Intensity: Getting the Dose Right
TMS intensity is set relative to something called the motor threshold, which is the minimum energy needed to produce a small, visible muscle twitch. Most protocols deliver pulses somewhere between 80 and 120 percent of that threshold. Too low, and the stimulation may not be strong enough to create meaningful change. Too high, and it can be uncomfortable or unnecessary.
Number and Spacing of Sessions
The traditional TMS protocol involves daily sessions, five days a week, for about six weeks. That approach is well studied and effective for many people, with response rates in the range of 49 percent and remission around 32 percent in large trials.
But research has also shown that changing the pace and dose of treatment can meaningfully change outcomes. Accelerated protocols, which deliver multiple sessions per day over a much shorter period, have been studied extensively by teams at Stanford and elsewhere. In controlled trials of one such accelerated protocol, remission rates as high as 78.6 percent were reported at the end of a five day treatment course, compared with an 11 percent drop in symptoms in the sham, or placebo, group. Not every patient needs an accelerated course, and not every accelerated protocol is built the same way, but the broader point stands: the number of sessions, how they are spaced, and the total dose delivered are treatment decisions, not afterthoughts.
Why Experience With Multiple Technologies Matters
Because location, intensity, and session structure all affect outcomes, and because every patient’s brain and history are different, a clinic that only offers one coil type and one fixed protocol has fewer tools to work with when the standard approach does not fit. If a patient does not respond well to a figure-eight coil at a standard target, a clinic with access to Deep TMS, personalized targeting, or accelerated protocols has other paths to try. A clinic without that range has to either tell the patient TMS did not work for them, or send them elsewhere.
This is really no different from other areas of medicine. A surgeon who only knows one technique will use it whether or not it is the best fit for the patient in front of them. The clinics that get the best results are the ones equipped, and experienced enough, to match the tool to the person.
Our Treatment Resistant TMS Pathway
At TMS Life, we built our practice around this idea. We work extensively with patients who have already tried standard antidepressant treatment, and sometimes have tried standard TMS elsewhere, without the results they hoped for. Our treatment resistant pathway is built on tracking real outcomes and adjusting the plan based on how each patient is actually responding, rather than running everyone through the same fixed protocol regardless of progress.
In practice, that might mean adjusting the stimulation site, changing the intensity, shifting from a standard course to a more intensive one, or incorporating other tools such as qEEG guided assessment or ketamine assisted therapy when appropriate. We have seen, over and over, that these adjustments are often the difference maker for people who had been told TMS was not going to work for them.
The Bottom Line
TMS can be a genuinely life changing treatment, but only when it is delivered thoughtfully. The location of stimulation, the intensity of the pulses, and the number and pacing of sessions are not small details. They are the treatment. If you are considering TMS, or if you tried it before and it did not help the way you hoped, it is worth asking any clinic what technologies and protocols they offer, and how they adjust care when a standard approach is not working. That conversation can tell you a great deal about the kind of outcome you are likely to get.
If you would like to talk through your history and find out whether a treatment resistant TMS pathway makes sense for you, our team at TMS Life is here to help.
References
Duprat, R. et al. Application of transcranial magnetic stimulation for major depression: Coil design and neuroanatomical variability considerations. Journal of Affective Disorders (2019).
Barbour, T. et al. Automated optimization of TMS coil placement for personalized functional network engagement. Neuron (2022).
Balderston, N. et al. A New Angle on Transcranial Magnetic Stimulation Coil Orientation: A Targeted Narrative Review. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging (2024).
Herbsman, T. et al. Severity of Depression Predicts Remission Rates Using Transcranial Magnetic Stimulation. PMC (2015).
Variability in Motor Threshold during Transcranial Magnetic Stimulation Treatment for Depression: Neurophysiological Implications. PMC (2023).
Cole, E. J. et al. Stanford Accelerated Intelligent Neuromodulation Therapy for Treatment-Resistant Depression (SAINT-TRD). American Journal of Psychiatry (2020).
Cole, E. J. et al. Stanford Neuromodulation Therapy (SNT): A Double-Blind Randomized Controlled Trial. American Journal of Psychiatry (2022).
Blumberger, D. M. et al. Effectiveness of theta burst versus high-frequency repetitive transcranial magnetic stimulation in patients with depression (THREE-D trial), cited in durability analyses of accelerated TMS. ScienceDirect (2025).
